MSHA Affiliation Agreement Checklist
Students cannot begin clinical rotations or internships until this form is submitted and approved by Organizational Development.

*All fields are required

Program/Discipline:   
School Name:
Instructor's Name:
Instuctor / School
Contact Email:
Affiliation Term:
Assignment Start Date:
Assignment End Date:



Please click all appropriate facility names to choose assignments requested for these students:

 + DCH





 + FWCH











 + IPMC













 + JCMC
























 + JMH










 + MSHA










 + MSMG



 + NCH








 + QRH








 + RCMC








 + SCCH








 + SSH












 + UCMH

 + WRH







Please provide a complete list of students that are coming to MSHA for assigned rotation. Please also add any instructor for these students who will need access during this semester:
First Name:
Middle Initial:  *Note - please contact Kimberly Kelley at KelleyKL@msha.com for any students/instructor that do not have a middle initial.
Last Name:
Last 5 Digits of SSN:
 

Current Submissions:



I verify the following:
  • The school instructor's licence (if applicable) is current and on file with the school.
  • All students listed on this form have completed course requirements for entry into this affiliation. A copy of the goals and objectives should also be given to the respective Preceptor or Unit Leader at Mountain States Health Alliance.
  • Current contract/certificate of current liability insurance is on file with Mountain States Health Alliance. Liability insurance in the amount of $1,000,000 individual, $3,000,000 annual aggregate is required for any student affiliating (unless otherwise approved) with Mountain States Health Alliance.


I verify that the following requirements have been met by the student and verified by the school prior to the affiliation/observation:
  • Each student has completed the MSHA online orientation and printed off the confirmation page for the school's file/record. The confirmation page indicates the student has reviewed and electronically signed/submitted the following documents:
    • MSHA online orientation confirmation and student orientation packet
    • Code of Ethics confirmation
    • Confidentiality Agreement
    • Immunizations -- Hepatitis B/GIV-PEP and Varicella Notice
  • Each student has provided proof of two (2) MMR vaccines after the first birthday OR proof of immunity by Titers. If student was born before 1957, he/she will not need to show proof. Proof is on file with school.
  • Each new student to MSHA has provided proof of negative Mantoux Tuberculin Skin Test within the previous 12 months. For returning students to MSHA, school will determine if student should get additional skin test before starting in clinical area. Persons with a history of TB or those who have previously tested PPD positive shall not have PPD testing but shall have a baseline chest x-ray. Proof is on file with school.
  • Each student has provided proof of a flu vaccination in the previous 12 months (for Spring and Summer semester only).
  • Each student has provided proof of CPR status.
  • Each student has a record of a physical/medical questionnaire on file with the school.
  • Each student has completed the electronic computer code request form (only applicable for students in clinical areas).
  • If student is a pharmacy intern, he/she has a valid pharmacy intern license for the state in which he/she is practicing.


I verify that the following background check status is true: (select one option)




NOTE: A departmental orientation should be conducted with all students. The departmental orientation should be completed with students for the unit/department where they are assigned at the beginning of their affiliation. The departmental orientation may be conducted by a representative of that department or by the school's instructor as appropriate.



I state that the information provided on this form is true, accurate, and complete to the best of my knowledge.

Name of person verifying information:
Title:
Date: